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HX64075346 
RA807.M38  F85      A  sickness  survey  of 


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Columbia  (initjers^ttp 

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llibrarp 


Digitized  by  tine  Internet  Archive 

in  2010  with  funding  from 

Open  Knowledge  Commons  (for  the  Medical  Heritage  Library  project) 


http://www.archive.org/details/sicknesssurveyofOOfran 


in^     U  .   -^  Lolumma  Umversit 

New  York. 


A  Sickness  Survey  of 
Boston,  Mass. 


Fourth  Community  Sickness  Survey 


BY 

LEE  K.  FRANKEL,  Ph.D. 

Sixth  Vice-President 

and 

LOUIS  I.  DUBLIN,  Ph.D. 
Statistician 


Metropowtan  Life  Insurance  Company 

New  York 

1916 


/ 


A  Sickness  Survey  of  Boston,  Massachusetts. 


Fourth  Community  Sickness  Survey. 


The  surveys*  already  made  by  the  writers  have  established 
the  efficacy  of  the  methods  employed  to  determine  the  basic 
facts  of  sickness  frequency  in  typical  American  communities. 
The  principal  findings  of  these  surveys  are  in  fimdamental 
agreement;  it  is  only  in  minor  details  that  differences  are 
found.  These  may  be  the  result  of  variations  in  the  race 
composition  of  the  several  populations,  the  geographical  and 
climatic  conditions,  the  principal  industries  followed,  the  sea- 
sons of  the  year,  etc.  The  fourth  survey  was  determined  upon 
in  order  to  develop  more  fully  the  practical  possibilities  arising 
out  of  such  inquiries.  The  city  of  Boston  was  chosen  for 
this  study  because  of  its  large  and  representative  population, 
its  geographical  location  and  its  varied  industrial  activity. 
The  appointment  of  a  Special  Commission  on  Social  Insurance 
by  the  Governor  of  Massachusetts  to  report  on  health  insurance 
among  other  matters,  suggested  the  possibility  that  our  find- 
ings for  Boston  might  be  especially  useful  to  this  body  in  its 
studies.  Finally,  the  excellent  medical  facilities  of  Boston,  in- 
cluding hospitals,  dispensaries,  a  well-developed  nursing  asso- 
ciation and  other  health  and  social  agencies,  confirmed  our 
decision  to  make  otu:  study  there.  It  was  hoped  that  the  facts 
developed  by  our  inquiry  might  be  put  to  practical  use  by 
placing  the  data  obtained  at  the  disposal  of  the  Commission 
and  of  the  several  institutions. 

The  survey  was  made  during  the  two  weeks  beginning  July 
17  and  July  24,  1916.  The  method  of  enumeration,  the  in- 
quiry form  (see  page  3  Rochester  Survey)  and  the  methods  of 
statistical  analysis  of  the  data  collected,  were  substantially 
the  same  in  the  fourth  survey  as  in  each  of  the  previous  ones. 
On  the  schedule,  only  one  important  addition  need  be  noted, 

*Frankel,  Lee  K.,  and  Dublin,  Louis,  I. 

Community  Sickness  Survey,  Rochester,  N.  Y.,  September,  1915. 

Public  Health  Reports,  February  25,  1916.     Also  as  Public  Health  Reprint  No.  326, 

U.  S.  Public  Health  Service,  Washington,  D.  C,  pp.  423-438. 
Community  Sickness  Survey,  North  Carolina,  April,  1916. 

Public  Health  Reports,  October  13,   1916,  pp.  2820-2844.      Also  as  a  Public  Health 

Reprint. 
U.  S.  Public  Health  Service,  Washington,  D.  C. 

I 


namely,  Question  8  incjuiring  into  the  presence  of  a  visiting 
nurse  in  the  care  of  the  sick.  In  tabulation  a  change  in 
interpretation  of  the  sick  "unable  to  work"  will  be  referred 
to  later.  A  series  of  conferences  were  held  with  the  Com- 
pany's agents  in  Boston,  the  reciuiremenls  of  the  schedule 
were  fully  explained  and  the  interest  of  the  men  actively 
aroused  to  further  the  aims  and  purposes  of  the  investigation. 
It  is  gratifying  to  record  the  fact  that  the  schedules  re- 
turned for  the  Boston  survey  show  in  every  essential  respect 
the  conscientious  response  of  the  agents.  Much  is  due  also 
to  the  fine  cooperation  extended  by  the  City  Department  of 
Health,  through  Dr.  Francis  X.  Mahoney,  Commissioner,  and 
by  the  public  press  and  medical  journals  of  Boston,  which  gave 
valuable  publicity  in  advance  of  the  inquiry  and  prepared  the 
community  to  receive  the  Company's  agents  cordially.  These 
efforts  were  of  distinct  value  in  creating  a  favorable  attitude 
toward  the  sickness  census  on  the  part  of  the  uninsured  public, 
the  medical  profession,  as  well  as  among  the  policy-holders 
of  the  Company. 

The  Company's  agents  canvassed  every  part  of  the  city 
of  Boston,  including  the  outlying  sections  of  Dorchester, 
Roxbury  and  South  Boston;  indeed,  the  entire  area  of  the  legal 
city  was  covered.  More  than  300  men  were  engaged  in 
the  survey.  Together  they  canvassed  20,497  families  and 
presented  returns  for  a  total  of  97,259  persons.  This  number 
is  about  13^"'f  of  the  total  estimated  population  of  the  Greater 
City  in  1916.  The  proportion  of  persons  canvassed  to  total 
population  is  only  slightly  lower  than  in  the  Rochester  survey. 
Internal  evidence  further  confirms  the  reliability  of  the  returns; 
thus,  the  number  of  persons  per  family,  4.7,  agrees  substantially 
with  that  found  (4.5)  for  Boston  families  canvassed  in  May, 
1915,  in  an  unemployment  survey  made  by  the  Metropolitan 
Life  Insurance  Company  for  the  United  States  Bureau  of  Labor 
Statistics. 

In  all,  1,902  cases  of  sickness  were  recorded.  This  is  equiva- 
lent to  a  rate  of  19.6  persons  sick  in  1,000  persons  canvassed, 
or  under  2%.  The  sickness  rate  is  fairly  constant  for  each 
of  the  several  districts  in  the  city.  The  rate  as  a  whole  is 
distinctly  lower  than  in  the  other  surveys;  the  lowest  previous 
rate  being  23.1  per  1,000  for  Rochester.  It  is  of  course  possible 
that  the  very  favorable  condition  shown  for  Boston  is  in  part 

2 


the  result  of  the  season  of  the  year  when  the  survey  was  made, 
namely,  the  mid-summer,  which  is  characterized  by  low  mor- 
tality and  by  very  low  incidence  of  respiratory  disorders,  as  we 
shall  see  later. 

Extent  of  Disability. 

Of  the  1,902  cases  of  sickness  discovered,  1,747,  or  91.9%, 
were  disabled  for  work,  and  155,  or  8.1%,  were  reported  sick 
but  able  to  work.  The  following  Table  1  gives  a  more  detailed 
presentation  of  the  facts  of  disability  among  the  entire  groups 
of  sick  persons : 

Table  1. 

Sickness  in  Boston,  Mass.,  Two  Weeks  Beginning  July  17,  1916, 

Classified  by  Extent  of  Disability  and  by  Sex. 


EXTENT  OF 
DISABILITY 

All  Persons 

Males 

Females 

No. 

Per  Cent, 
of  Total 

No. 

Per  Cent, 
of  Total 

No. 

Per  Cent, 
of  Total 

All  Classes  .... 

1,902 

100.0 

935 

100.0 

967 

100.0 

Unable  to  work  . . 

In  bed  at  home 

In  hospital .... 

Up  and  about . 

Dispensary. .  .  . 
Able  to  work .... 

Dispensary. .  .  . 

1,747 
326 
337 

1,084 

153 

155 

3 

91.9 
17.1 

17.7 

57.0 

8.0 

8.1 

.2 

850 

123 

201 

526 

79 

85 

2 

90.9 

13.2 
21.5 

56.3 
8.4 
9.1 

2 

897 

203 

136 

558 

74 

70 

1 

92.8 
21.0 
14.1 

57.7 

7.7 

7.2 

.1 

The  distribution  of  the  sick  persons  according  to  the  extent 
of  disability  is  appreciably  different  in  this  survey  from  that 
found  in  the  previous  ones.  Thus,  in  North  Carolina  the 
per  cent,  of  "unable  to  work"  to  total  sick  was  only  80.4; 
in  Rochester,  it  was  82.8;  in  Boston,  the  corresponding  figure 
was  91.9%.  This  difference  has  resulted  largely  from  a  change 
in  the  method  of  classifying  the  cases  returned  with  ability 
to  work  "unspecified."  In  the  previous  investigations  these 
cases  were  assumed  uniformly  to-be  "able  to  work."  In  the 
Boston  survey  it  appeared  altogether  more  reasonable  to 
classify  these  imspecified  returns  on  the  basis  of  the  internal 
evidence  present  in  each  case.  As  a  result,  a  large  proportion 
of  the  unspecified  cases  were  found  "unable  to  work."  It  is 
our  belief  that  this  method  results  in  a  tabulation  much  nearer 
the  truth. 

The  proportion  of  cases  of  sickness  receiving  hospital 
treatment  was  larger  in  Boston  than  in  any  of  the  three  areas 

3 


l)reviously  surveyed.  It  was  17.7%  of  total  sick  as  against 
2.4''o  in  North  Carolina  and  10.7%  in  Rochester.  This  finding 
is  consistent  vvith  the  extensive  hospital  facilities  of  Boston 
in  relation  to  population.  There  are  about  ten  times  more 
hospital  beds  per  unit  of  population  in  Boston  than  in  North 
Carolina,  and  this  condition  is  reflected  in  the  proportions  of 
cases  receiving  hospital  care  among  the  sick  persons  registered 
in  the  two  areas. 

It  was  found  feasil)le  also  to  tabulate  the  number  of  ambulant 
cases  receiving  "dispensary"  care  among  the  sick.  8.2^o  f>f 
the  sick  were  under  treatment  at  dispensaries  as  out-patients. 
Nearly  all  the  dispensary  cases  were  unable  to  work,  only 
three  being  recorded  otherwise.  vSince  dispensary  authorities 
have  found  that  a  large  proportion  of  their  adult  cases  are  at 
work,  it  would  appear  that  our  method  of  study  is  not  well 
adapted  to  discover  all  the  cases  of  sickness  not  resulting  in 
incapacity  to  work. 

No  significant  differences  in  the  extent  of  disability  were 
observed  in  the  two  sexes.  A  marked  difference  is  to  be  noted, 
however,  in  the  proportions  of  cases  "  in  bed  at  home"  and  "in 
hospital"  for  the  two  se.xes.  The  relations  between  these  two 
sets  of  figures  are  apparently  reversed,  the  males  having  a 
liigher  hospital  proportion  (21.5%)  and  the  females  a  higher 
proportion  of  "in  bed  at  home"  cases  (21.0%). 

Sickness  by  Sex  and  by  Age  Period. 

Among  the  97,259  persons  enumerated  in  the  survey,  1,902 
cases  of  sickness  were  discovered,  or  at  a  rate  of  19.6  per  1,000. 
vSickness  involving  disability  for  work  was  enumerated  in  1,747 
instances,  or  at  a  rate  of  18.0  per  thousand  persons  exposed. 
We  shall  now  consider  these  facts  of  sickness  with  due  regard 
for  sex  and  age.  Among  the  males,  19.9  persons  were  sick 
for  each  1,000  exposed;  the  figure  for  females  was  19.5  per 
thousand.  vSickness  involving  disability  for  work  occurred  at 
a  rate  of  18.1  per  thousand;  the  same  rate  of  sickness  was 
observ'ed  for  females.  The  sickness  rate  for  males  in  Boston 
was  1.5  cases  per  1,000  less  than  that  registered  for  Rochester, 
N.  Y.,  and  5.2  points  less  per  1,000  than  the  rate  for  white 
males  in  North  Carolina.  The  sickness  rate  for  females  in 
Boston  (19.5  per  thousand)  was  5.3  points  lower  than  in 
Rochester  and  13.1  points  lower  than  the  rate  for  white  females 
in  North  Carolina. 


Table;  2. 

Number  of  Cases  and  Rates  per  1,000  Exposed  by  Age  and  Sex 
Total  Sick,  and  Sick  Unable  to  Work. 


Number  of 
persons 
exposed 

Total  sick  persons 

Sick  persons  UNiBLE 

TO  WORK 

SEX  AND  AGE  PERIOD 

Number 

Rate 
Per  1,000 
expooed 

Number 

Rate 
Per  1,000 
exposed 

AtL  Persons : 

All  ages 

97,259 
64,028 

1,902 
1,538 

19.6 
24.0 

1,747 
1,389 

18.0 

15  years  and  over. . 

21.7 

Under  IS 

15-24 

25-34 

35-44 

45-54 

55-64 

65  and  over. 
Unknown  age 

32,519 

17,584 

16,261 

13,828 

9,211 

4,789 

2,355 

712 

358 
205 
258 
288 
300 
246 
241 
6 

11.0 
11.7 
15.9 
20.8 
32.6 
51.4 
102.3 

353 
195 
226 
258 
265 
216 
229 
5 

10.9 
11.1 
13.9 

18.7 
28.8 
45.1 
97.2 

Mai.es  : 

All  ages 

46,911 
30,792 

935 
748 

19.9 
24.3 

850 
665 

18.1 

15  years  and  over. . 

21.6 

Under  15 

15-24 

.    25-34 

35-44 

45-54 

55-64 

65  and  over. 
Unknown  age 

16,010 
8,495 
7,862 
6,794 
4,506 
2,149 
986 
109 

186 
90 
112 
147 
170 
118 
111 
1 

11.6 
10.6 
14.2 
21.6 
37.7 
54.9 
112.6 

185 
87 
90 
131 
145 
104 
108 

11.6 
10.2 
11.4 
19.3 
32.2 
48.4 
109.5 

Females  : 

All  ages 

49,640 
33,153 

967 
790 

19.5 
23.8 

897 
724 

18.1 

15  years  and  over.  . 

21.8 

Under  15 

15-24 

25-34 

35-44 

45-54 

55-64 

65  and  over. 
Unknown  age 

16,380 
9,060 
8,375 
7,025 
4,688 
2,636 
1,369 
107 

172 
115 
146 
141 
130 
12-8 
130 
5 

10.5 
12.7 
17.4 
20.1 
27.7 
48.6 
95.0 

168 
108 
136 
127 
120 
112 
121 
5 

10.3 
11.9 
16.2 
18.1 
25.6 
42.5 
88.4 

Sex  not  stated 

708 

The  rates  for  sickness  involving  disability  for  work  increased 
regularly  with  age  for  both  sexes.  The  consistency  of  the 
rates  with  respect  to  age  period  may  be  considered  as  good 
evidence  of  the  substantial  character  of  the  material  repre- 

5 


Graph  I 


CosesofSicnness per  1000  Expose^ci Persons 
Boston,  Mass.,  WeeK  of  Jul^  11,1^  llo. 


I^ott  per  1,000 


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sented  in  this  enumeration.  The  graph  on  page  6  illustrates 
the  course  of  the  sickness  rates  with  respect  to  age  period  for 
the  group  of  total  sick  persons  among  males  and  females 
respectively. 

In  the  first  two  age  periods  the  sickness  rate  of  females 
exceeds  that  of  males.  The  incidence  of  puerperal  conditions 
in  this  period  of  life  no  doubt  accounts  for  this  excess  of  dis- 
abling sickness  among  females.  This  slight  irregularity  in 
the  sickness  rates  for  adult  females  is  a  characteristic  of  general 
morbidity  statistics  wherever  observed.  Beginning  with  the 
age  period  35-44  and  continuing  uniformly  thereafter,  the 
rates  for  the  females  are  appreciably  lower  than  for  the  males. 

Sickness  in  Boston  by  Disease. 

The  more  important  diseases  and  conditions  enumerated 
in  the  survey  are  shown  in  Table  3.     (See  pages  8-9.) 

Varied  climatic,  geographical  and  other  environmental 
conditions  affect  the  actual  and  relative  frequency  of  the  several 
diseases  and  conditions.  In  the  North  Carolina  and  Rochester 
surveys,  rheumatism  in  its  various  forms  constituted  the 
single  disease  or  condition  of  highest  numerical  importance. 
In  the  Boston  survey,  however,  the  title  "External  Causes" 
led  the  list  with  a  rate  of  198.4  per  100,000  exposed.  Rheu- 
matism was  the  cause  next  in  importance,  with  a  rate  of  180.0 
per  100,000,  or  11.1%  less  than  the  North  Carolina  rate  and 
15.0%  less  than  the  Rochester  finding. 

Organic  diseases  of  the  heart  were  observed  in  91  cases  in 
the  Boston  survey  and  constituted  5.2%  of  the  total  sicknesses 
registered.  The  rate  was  93.6  per  100,000.  The  Boston 
rate  for  organic  diseases  of  the  heart  approaches  the  one  dis- 
covered in  Rochester,  but  is  about  one-third  greater  than  the 
North  Carolina  rate.  Tuberculosis  of  the  lungs  was  found 
in  82  cases,  or  at  the  rate  of  84.3  per  100,000.  This  is  the 
lowest  tuberculosis  rate  so  far  discovered  in  the  several  surveys. 
This  disease  constituted  4.7%  of  the  total  sickness  recorded 
among  the  group  of  sick  persons  unable  to  work.  Cerebral 
hemorrhage,  apoplexy  and  paralysis  were  present  in  81  cases 
at  a  rate  of  83.3  per  100,000.  The  rate  for  this  disease  was 
lower  in  Boston  than  in  the  North  Carolina  or  the  Rochester 
inquiries.  One-fifth  of  all  the  diseases  and  conditions  recorded 
affected  the  nervous  system  and  organs  of  special  sense ;  which 

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fact  recalls  the  high  prevalence  of  nervous  disorders  registered 
in  the  Rochester  survey.  Diseases  and  conditions  of  the 
puerperal  state  were  enumerated  in  56  instances  at  a  rate 
of  57.6  per  100,000.  This  rate  compares  well  with  that  for 
North  Carolina,  but  was  exceeded  by  about  one-half  by  the 
Rochester  rate.  Diseases  of  the  kidneys  and  annexa  were 
registered  in  37  cases  at  a  rate  of  38.0  per  100,000.  The 
rate  for  this  group  of  diseases  and  conditions  was  the  lowest  of 
any  of  the  three  recorded  in  our  surveys.  "  Colds  "  and  diseases 
of  the  respiratory  system,  such  as  bronchitis  and  pneumonia 
were  present  to  a  lesser  degree  in  Boston  than  in  the  North 
Carolina  survey  which  was  taken  in  mid-spring.  Thus,  the 
sickness  rate  for  "colds"  (17.5),  was  about  one -half  of  that 
registered  for  Rochester  and  about  one-third  the  rate  for  the 
North  Carolina  survey.  Pneumonia  had  a  rate  slightly  in 
excess  of  that  for  Rochester;  the  Boston  rate  was  very  nearly 
one-fourth  the  rate  for  the  North  Carolina  survey.  In  the  low 
rates  for  both  "colds"  and  pneumonia  we  can  readily  discern 
the  influence  of  the  season  of  the  year. 

Disease  by  Age. 

The  cases  of  sickness  recorded  in  the  survey  have  already 
been  considered  with  respect  to  their  relative  frequency  at 
the  several  broad  divisional  periods  of  life.  We  shall  now 
consider  some  of  the  individual  diseases  in  relation  to  age 
period.  In  the  group  of  ages  under  15,  the  acute  infectious 
diseases  of  children  have  their  greatest  frequency;  95  out  of 
the  total  of  100  cases  of  such  diseases  occurred  at  this  time  of 
life.  "Colds"  and  bronchitis  were  also  prominently  repre- 
sented in  the  ages  under  15 ;  21  such  cases  out  of  a  total  of  41 
were  thus  registered.  Tonsillitis  and  other  diseases  of  the 
phar}'nx  occurred  most  frequently  at  these  ages,  in  19  cases 
out  of  a  total  of  24  at  all  ages.  Ten  of  the  sixteen  cases  of 
diarrhea  and  enteritis  also  occurred  at  this  period. 

During  the  period  of  life  between  the  ages  15  and  34  years, 
tuberculosis  of  the  lungs  was  prominently  identified;  38  cases 
out  of  a  total  of  90  occurred  in  this  age  period.  Appendicitis 
was  also  observed  to  be  fairly  well  concentrated  in  this  period 
of  life,  in  23  cases  out  of  a  total  of  35.  Diseases  and  conditions 
of  the  puerperal  state  have  their  special  incidence  in  this  age 
period;  47  out  of  a  total  of  59  such  cases  were  found.     A  little 

10 


more  than  one-quarter  of  the  total  cases  of  sickness  and  disa- 
bility from  external  causes  were  registered  between  the  ages 
15  and  34. 

The  third  period  of  life  under  observation,  ages  35  to  54, 
was  characterized  by  a  larger  representation  of  the  chronic 
diseases  than  either  of  the  two  divisional  periods  previously 
considered;  tuberculosis  of  the  lungs  showed  40  out  of  a  total 
of  90  cases,  all  forms  of  rheumatism  72  out  of  201  cases,  mental 
alienation  21  cases  out  of  a  total  of  34.  Eighty-one  instances 
of  sickness  due  to  external  causes  were  registered  in  this  third 
age  period. 

In  the  final  age  period,  including  all  the  ages  55  and  over, 
rheumatism,  as  was  to  be  expected,  showed  its  highest  pro- 
portionate frequency,  namely,  93  out  of  a  total  of  201  cases. 
Cerebral  hemorrhage,  apoplexy  and  paralysis  showed  57  cases 
in  this  age  period  out  of  a  total  of  83  at  all  ages.  Organic 
diseases  of  the  heart  and  diseases  of  the  kidneys  and  annexa 
were  also  prominently  represented  in  this  last  age  period. 

Certain  diseases  registered  in  this  survey,  such  as  neuralgia 
and  neuritis,  pneumonia,  diseases  of  the  skin  and  diseases  of 
the  bones  were  fairly  well  distributed  over  the  entire  range  of 
life. 

Table  4  shows  these  facts  in  greater  detail.  (See  pages  12-13.) 

Duration  of  Sickness. 

Table  5  on  page  14  gives  a  display  of  the  total  sick- 
nesses distributed  by  the  duration  periods  specified  in  the 
enumeration. 

In  a  total  of  1,902  cases  of  sickness  reported,  the  duration 
of  the  illness  up  to  the  date  of  inquiry  was  specified  in  1,853 
instances.  More  than  one-quarter  of  the  known  cases  (26.3%) 
reported  durations  of  illness  less  than  one  month;  39.1%  were 
reported  sick  for  a  period  less  than  three  months,  and  48.4%  or 
very  nearly  half  of  the  total  cases  showed  a  sickness  period  of 
less  than  six  months.  These  percentages  approximate  very 
closely  the  ones  reported  for  the  Rochester  material,  but  are 
considerably  different  from  those  for  the  North  Carolina  survey. 
In  the  latter  inquiry  a  large  number  of  acute  diseases  and  con- 
ditions were  discovered,  and  this  very  decidedly  increased  the 
proportion  of  cases  sick  for  short  periods  of  time. 

11 


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Table  5. 

Xunibcr  of  Cases  of  Sickness  at  Eaeli  Duration  Period  in  Boston, 

Mass. 


DURATION  OF  SICKNESS 

No.  of  cases 

in  specified 

duration  period 

Percentage  of 

total  known 

durations 

All  durations 

1,<)02 

lUO.O 

34 

136 

145 
86 
82 

150 

ss 

172 
168 
315 
477 
49 

1.8 

1  day  to  1  week 

7.3 

1  week  to  2  weeks 

7.8 

2  weeks  to  3>  weeks 

4.8 

.^  weeks  to  1  month    

4.6 

1  month  to  2  months 

8.1 

2  months  to  3  months 

4.7 

3  months  to  6  months 

9.3 

6  months  to  1  year 

1  year  to  3  years 

3  years  and  over 

9.1 
17.0 

25.7 

I'nspecified  

Among  the  1,747  persons  sick  and  unable  to  work  the 
duration  of  illness  was  specified  in  1,706  cases.  About  one-half 
of  these  with  specified  durations  of  sickness  (47.9%)  had 
been  sick  less  than  six  months  prior  to  the  day  of  the  inquiry. 
The  corresponding  figure  for  Rochester  was  40.7%  and  for 
North  Carolina  67.0%.  When  distributed  over  the  eleven 
specified  duration  periods  the  Boston  cases  were  found  to 
approximate  closely  those  for  Rochester.  As  pointed  out 
before,  the  large  number  of  cases  of  acute  diseases  in  North 
Carolina  seriously  disturbed  the  general  distribution  of  total 
persons  sick  and  unable  to  work.  As  was  to  be  expected,  the 
chronic  diseases,  such  as  tuberculosis  of  the  lungs,  cancer  and 
diseases  of  the  heart,  have  their  greatest  incidence  in  the  periods 
of  long  duration. 

Table  6,  opposite,  presents  some  of  the  important  diseases 
and  conditions  among  the  sick  unable  to  work,  classified  by 
duration  of  illness  and  by  sex . 

The  number  of  persons  sick  but  able  to  work  was  155,  and 
among  these  the  duration  of  illness  was  specified  in  147  instances. 
As  in  our  pre\'ious  surv^eys,  we  found  that  the  greater  proportion 
of  these  cases  were  chronic  diseases  with  durations  longer  than 
six  months.  The  small  number  of  such  cases  registered  did 
not  permit  of  any  extensive  tabulation  according  to  disease  or 
condition. 

14 


Tabl^  6. 

iber  of  Persons  by  Specified  Durations  of  Sickness  to  Date  of  Inquiry,  by  Disease  c 
Condition  and  by  Sex.     Persons  Sick  and  Unable  to  Work. 


iSB  OR  CONDITION;  SEX 


iseases  and  conditions 

ales 

males 

jles : 

ales 

males 

oping-cough : 

ales 

laales 

rculosis  of  the  lungs: 

ales 

males 

imatism: 

ales 

males 

;bral     hemorrhage, 
oplexy  and  paralysis: 

ales 

;males   

irvousness,"    "  run- 
iwn": 

ales 

'.males 

mic    diseases    of    the 
art: 

ales 

;male? 

imonia  (all  forms) : 

ales 

imales 

gestion  and  other  dis- 
ses  of  the  stomach : 

ales 

;males 

ases   of   the    kidneys 
id  annexa: 

ales 

imales 

mal  childbirth : 
;males 

ir   puerperal   diseases 
id  conditions: 
imales ,    ,    .  . 

;mal  causes ; 

!ales 

imales • 

)ther  diseases  and  con- 
tions : 

;ales 

imales 


All 
durations 


1,747 
850 
897 


23 
21 

15 
24 

55 
27 

70 
105 


31 
50 


35 
86 


42 
49 

18 


31 

41 


21 
16 

50 


138 

55 


371 
359 


1 
day- 


Over  1 
day  and 
under 
1  week 


135 
64 
71 


10 

2 
2 


13 


15 


34 
28 


1  week 

and 

under 

2  weeks 


141 
58 
83 


1 

24 


26 
23 


2  weeks 
and 

under 

3  weeks 


82 
38 
44 


17 
20 


3  weeks 
and 
under 
1  mo. 


81 
39 

42 


1  mo. 

and 

under 

2  mos. 


146 
82 
64 


20 
9 


34 
24 


2  mos. 
and 

under 

3  mos. 


79 
40 
39 


4 
10 


14 
13 


3  mos. 

and 

under 

6  mos. 


154 
80 
74 


13 


6  mos. 

and 

under 

1  year 


153 


2 
10 


18 

8 


29 
34 


1  year 

and 

under 

3  years 


281 
132 
149 


16 
9 

20 
29 


13 


48 
62 


15 


Medical  Attendance. 

Of  the  1,902  cases  of  sickness,  1,386,  or  72.9%,  had  medical 
attendance.  The  proportion  is  considerably  higher  than  that 
found  for  Rochester  (61.0%),  or  that  for  North  Carolina 
(61.5%).  This  is  in  part  explained  by -the  character  of  the 
illnesses  recorded  and  by  the  exceptional  facilities  in  and  about 
Boston  for  securing  medical  attendance.  According  to  the 
latest  available  data,  there  were  in  Greater  Boston  275.4 
medical  practitioners  per  1,000  of  population.  This  figure  may 
be  compared  with  1 7 1 .4  per  1 ,000  for  Rochester,  New  York  and 
83.3  per  1,000  for  the  entire  State  of  North  Carolina.  In 
addition,  we  must  keep  in  mind  the  many  hospitals,  dispensaries, 
nursing  associations  and  other  agencies,  public  and  private, 
that  serve  the  sick  in  Boston.  The  group  of  persons  sick 
and  unable  to  work  had  ph3'sicians  in  attendance  in  74.7% 
of  the  cases.  For  the  small  group  of  persons  sick  but  able  to 
work,  only  52.3%  had  physician  in  attendance. 

The  proportion  of  cases  with  medical  attendance  varied,  of 
course,  with  the  several  diseases  and  conditions.  Thus,  all 
the  cancer  cases  sick  and  unable  to  work  w-ere  under  observation 
of  a  physician  as  were  also  all  of  the  pneumonia  cases.  Tuber- 
culosis of  the  lungs  showed  a  very  high  proportion  of  the  cases 
under  the  care  of  a  physician  (91.5%).  About  two-thirds  of 
the  cerebral  hemorrhage,  apoplexy  and  paralysis  cases,  one-half 
of  the  rheumatism  cases,  and  about  three-quarters  of  the  cases  of 
stomach  and  kidney  disease  had  physicians  in  attendance. 
Table  7,  on  page  17,  will  indicate  the  proportion  of  cases 
with  physician  in  attendance  in  the  principal  diseases . 

It  is  a  matter  of  importance  to  know  the  kind  of  medical 
attendance  in  cases  of  sickness,  that  is,  whether  the  care  is  by 
private  physician,  hospital  or  dispensary.  Table  8,  on  page  18, 
shows  these  facts  for  all  diseases  and  conditions  combined, 
classified  by  extent  of  disability. 

Very  nearly  two-thirds  of  the  total  cases  of  sickness  under 
medical  care  were  treated  by  private  physicians ;  less  than  one- 
quarter  were  under  treatment  in  hospitals,  and  the  remainder  of 
those  under  any  kind  of  medical  observation  were  treated  by 
dispensary  physicians.  These  facts  on  kind  of  medical  attendance 
are  interesting  in  relation  to  the  several  diseases  and  conditions 
found  among  the  sick  and  unable  to  work.  Thus,  out  of  a  total  of 

16 


Table  7. 


Number  of  Cases  Attended  by  Physician  or  Treated  in  Institution 
by  Sex  and  by  Extent  of  Disability. 


EXTENT  OF  DISABILITY  AND  SEX 

Total 
cases 

Physician 

in 
attendance 

Per  cent. 

Phvs.  in 

attendance 

AblB  and  Unable  to  Work. 
All  diseases  and  conditions : 

1,902 
935 

967 

1,386 
685 
701 

72.9 

Males 

Females 

73.3 

72.5 

Unable  to  Work 
All  diseases  and  conditions : . .  . 

1,747 
850 
897 

1,305 
641 
664 

74.7 

Males 

Females 

75.4 
74.0 

Tuberculosis  of  the  lungs : 

Males ....            

55 
27 

4 
14 

70 
105 

31 

50 

42 
49 

18 
8 

31 
41 

21 
16 

575 
579 

155 

85 
70 

49 
26 

3 
14 

40 
51 

20 
30 

31 
41 

18 

8 

22    " 
34 

16 

13 

440 
439 

81 
44 

37 

89.1 

Females 

96.3 

Cancer: 

Males 

75.0 

Females 

100.0 

Rheumatism : 

Males 

57.1 

48.6 

Cerebral  hemorrhage.apoplexy  &  paralysis : 
Males                         

64.5 

Females                             

60.0 

Organic  diseases  of  the  heart : 

Males                         

73.8 

83.7 

Pneumonia  (all  forms) : 

100.0 

100.0 

Diseases  of  the  stomach: 

Males             

71.0 

82.9 

Diseases  of  the  kidneys  and  annexa: 

76.2 

81.3 

All  other  diseases  and  conditions : 

76.5 

75.8 

Able  to  Work 

52.3 

51.8 

Females 

52.9 

Tuberculosis  of  the  lungs : 

Males                             

8 

4 

50.0 

12 
14 

11 
14 

3 

5 

5 
3 

46 

34 

4 
3 

7 
9 

3 

4 

3 
3 

23 
18 

33.3 

21.4 

Diseases  of  the  nervous  system: 

Males                   

63.6 

64.3 

100.0 

80.0 

Diseases  of  kidneys  and  annexa: 

60.0 

100.0 

50.0 

52.9 

Table  8. 

Number  and  Percentage  of  Cases  in  Care  of  Specified  Medical 
Services  by  Extent  of  Disability. 


CHAR.\CTER  OF 

Total 
sick  persons 

Sick 

VN.tBLE  TO  WORK 

Rick 

ABl.K  TO  WORK 

No. 

P.r  Cent. 

No. 

PtT  Cent. 

No. 

Per  Cent. 

Total  with  physician  in 
attendance 

1,386 

100.0 

1.305 

100.0 

81 

100.0 

Private  physician 

Hospital 

Dispensary 

894 
336 
156 

64.5 
24.2 
11.3 

816 
336 
153 

62.5 
25.7 
11.7 

78 

'i 

96.3 
"3"7 

44  measles  cases,  29  were  under  the  care  of  a  private  physician 
and  15  were  registered  as  having  no  medical  attendance  of  any- 
kind.  All  of  the  scarlet  fever  cases  were  under  the  care  of  a 
physician.  Five  of  them  were  in  hospitals  and  4  were  under 
the  observation  of  private  practitioners.  Whooping-cough 
cases  showed  22  as  without  physician  in  attendance,  15  under 
private  medical  care,  2  in  hospital.  Seven  out  of  8  diphtheria 
cases  were  in  hospital  and  1  was  under  the  care  of  a  private 
physician. 

The  medical  care  of  tuberculosis  cases  is  apparently  well 
developed  in  Boston.  In  all,  90  cases  of  tuberculosis  of  the 
lungs  were  registered.  Of  these,  1 1  had  no  physician  in  at- 
tendance, of  whom  four  were  able  to  work.  Twenty-six  of  the 
cases  of  tuberculosis  were  under  the  care  of  private  physicians, 
52  were  in  hospitals  or  sanatoria,  and  1  was  receiving  medical 
care  at  a  dispensary.  Two  cases  of  cancer  out  of  a  total  of 
19  were  without  medical  attendance;  2  were  in  hospitals  and  4 
were  receiving  dispensar\^  care.  Rheumatism,  a  disease  which 
constituted  a  very  large  proportion  of  the  total  cases  of  sick- 
ness, was  not  under  medical  observation  in  103  out  of  201 
cases.  Private  physicians  were  caring  for  76,  hospitals  for  8, 
and  dispensaries  for  14  of  these  rheumatism  cases.  Cerebral 
hemorrhage,  apoplexy  and  paralysis  w^ere  not  under  the  care 
of  a  physician  in  32  out  of  83  cases.  Private  physicians  had  41, 
hospitals  had  9  and  dispensaries  had  1  of  these  cases.  All  of 
the  34  cases  of  mental  alienation  (insanity)  were  under  hospital 
care.  Diseases  of  the  nervous  system  reported  by  the  enumera- 
tors as  "run-down"  or  "nervousness"  (130  cases),  had  no 
physician  in  attendance  in  22  instances.     Private  physicians 

18 


were  caring  for  76  cases,  hospitals  for  22  and  dispensaries  for 
10  of  the  cases  registered.  Out  of  99  cases  of  organic  diseases 
of  the  heart,  20  were  without  physician  in  attendance;  62  had 
private  physicians;  10  were  in  hospitals  and  7  were  dispensary 
cases.  Pneumonia  showed  21  cases  with  private  physician  in 
attendance  and  5  in  hospital  out  of  a  total  of  27  cases.  Of  35 
cases  of  appendicitis,  10  were  found  to  be  under  the  care  of  a 
private  physician,  2 1  in  hospital,  2  under  dispensary  observation, 
and  2  had  no  physician  in  attendance.  The  45  cases  of  diseases 
of  the  kidneys  and  annexa  showed  that  25  were  under  the  care 
of  a  private  physician  and  9  in  hospital.  These  facts  are  shown 
in  Table  9,  on  the  opposite  page. 

To  recapitulate,  hospitals  cared  for  a  total  of  336  cases, 
and  among  these  there  were  chiefly  tuberculosis  of  the  lungs 
(52  cases),  mental  alienation  (34  cases)  and  accidents  and 
injuries  (40  cases).  Other  diseases  well  represented  under 
those  treated  in  hospitals  were  diseases  of  the  nervous  system, 
other  than  mental  alienation  (52  cases),  organic  diseases  of 
the  heart'(10  cases),  diseases  of  the  stomach  (12  cases),  diseases 
of  the  kidneys  and  annexa  (9  cases)  and  normal  childbirth 
(10  cases).  The  entire  distribution  of  the  hospital  cases  by 
disease  and  condition  gives  an  impression  consistent  with  other 
statistics  of  cases  under  treatment  in  general  hospitals. 

Dispensary  service  was  registered  in  156  cases,  and  presents 
a  quite  different  aspect  as  to  diseases  and  conditions.  Acci- 
dents and  injuries  were  the  chief  conditions  treated  in  dis- 
pensaries (29  cases).  Rheumatism  (14  cases),  "nervous"  and 
"run-down"  conditions  (10  cases),  organic  diseases  of  the 
heart  (7  cases),  diseases  of  the  stomach  (7  cases),  were  the 
diseases  and  conditions  next  in  importance  among  those  treated 
in  dispensaries.  We  are  concerned  here  mostly  with  cases  of 
minor  importance  in  which  the  patients  are  still  up  and  about 
even  if  incapacitated  for  work. 

In  the  Boston  survey  an  additional  inquiry,  not  found  in 
the  three  previous  studies,  put  at  our  disposal  facts  with 
reference  to  Visiting  Nurse  Service  in  attendance  upon  the 
sick.  Thus,  we  found  134  cases  receiving  the  attention  of  a 
Visiting  Nurse.  Seven  were  measles  cases  out  of  a  total  of  29 
recorded  as  having  medical  attention  but  receiving  neither 
hospital  nor  dispensary  care.  Four  were  cancer  cases  out  of  a 
total  of  11  which  received  medical  attention  outside  of  hos- 

19 


Table  9. 


Xumher  of  Cases  of  Sickness  Under  Care  of  Specified  Medical 
Service.     Diseases  and  Conditions  for  Total  Sick  Persons. 


DISEASE  OR   CONDITION 


All 
cases 


Ca8E8  with  physician  in  attendance 


Total 

with 

physician 


Private 

physician 


Hoi--pit:il 


Dispeii- 


Visiting 
nurse  in 
atten- 
dance 


All  diseases  and  conditions — 
both  sexes 

Males 

Females 

Measles 

Scarlet  fever 

Whooping-cough 

Diphtheria  and  croup 

Tuberculosis  of  the  lungs ... 

Cancer — all   forms 

Rheumatism 

Cerebral  hemorrhage,  apoplexy 
and  paralysis 

Mental  alienation  (insanity) 

"Run-down"  and  "nervous- 
ness"  

Organic  diseases  of  the  heart 

Pneumonia — all  forms 

Diseases  of  the  stomach 

Appendicitis*' 

Diseases  of  the  kidneys  and 
annexa  

Normal  childbirth  and  other 
puerperal  diseases  and 
conditions 

External  causes  (accidents  and 
injuries) 

All  other  diseases  and  con- 
ditions   


1,902 

935 
967 


1,386 

685 
701 


4-i 
9 

39 
8 

90 

19 
201 

83 
34 

130 
99 
27 
86 
35 

45 

59 
201 
696 


29 

9 

17 

8 
79 

17 
98 

51 
34 

108 
79 
26 
65 
33 

35 

53 
174 


894 

403 
491 


29 
4 

15 
1 
26 
11 
76 

41 

76 
62 
21 
46 
10 

25 

42 

105 


471        304 


336 


201 
135 


52 


9 
34 

22 
10 
5 
12 
21 


10 
40 

88 


156 


81 
75 


1 

4 

14 


10 


1 
29 
79 


134 

33 
101 


4 
15 


6 

11 

2 

4 


20 
12 
43 


20 


pital  or  dispensary.  Fifteen  were  rheumatism  cases  out  of  a 
total  of  76  having  private  physician  and  eleven  were  cases  of 
organic  heart  disease  out  of  a  total  of  62  having  private 
physician  in  attendance.  Twenty  out  of  42  were  cases  of  the 
puerperal  state  tmder  medical  attention.  Only  two  out  of  21 
pneumonia  cases  had  a  Visiting  Nurse;  finally  only  twelve 
cases  of  accidents  and  injuries  out  of  105  with  private  phy- 
sician were  so  treated.  It  is,  therefore,  questionable  whether 
public  health  nursing  in  Boston  is  generally  available  for  a 
large  number  of  cases  of  sickness  which  it  is  agreed  are  well 
served  by  this  medical  auxiliary. 

The  following  table  shows  the  principal  diseases  and  con- 
ditions nursed  among  the  policy-holders  of  the  Metropolitan 
Life  Insurance  Company  during  1915  and  serves  in  this 
connection  as  a  basis  of  comparison  with  the  data  shown  in 
Table  9  (page  20). 

TabliS  10. 

Number  and  Percentage  of  Cases  Visited  in  Boston,  Mass.,  During 

1915  by    Visiting  Nurse  Service  of  Metropolitan  Life 

Insurance  Company.     Principal  Diseases  and 

Conditions  Nursed  and  Advised,  with 

Physician  in  Attendance. 


DISEASE  OR  CONDITION 


Percentage  of  total 


All  diseases  and  conditions . 


Typhoid  fever 

Measles,   scarlet    fever,    whooping-cough, 

diphtheria  and  croup 

Tuberculosis  of  lungs 

Rheumatism,  acute  and  chronic 

Pneumonia — all  forms 

Diseases  of  digestive  system 

Tonsillitis 

Puerperal  state 

External  causes - 

All  other  diseases  and  conditions 


The  proportions  of  cases  of  certain  diseases  receiving  Visiting 
Nurse  care  in  the  survey  agreed  fairly  closely  with  the  pro- 
portions for  these  diseases  in  the  entire  Visiting  Nurse  Service 
of  the  Company  in  Boston  during  1915.  Thus,  during  this 
year  the  Visiting  Nurse  Service  had  6.5%  of  its  cases  registered 
under  the  four  communicable  diseases  of  childhood  (measles, 
scarlet    fever,    whooping-cough,    diphtheria);    in    the    nursed 

21 


cases  registered  by  the  survey,  6.7%  of  the  cases  were  classified 
under  this  heading.  Diseases  and  conditions  of  the  puerperal 
state  constituted  19.9%  of  the  cases  registered  in  the  Visiting 
Nurse  Service  and  14.9%  of  the  nursed  cases  enumerated  in 
the  survey.  With  due  consideration  for  dilTerences  in  season 
of  the  year  and  other  limiting  circumstances,  we  think  that  there 
is  fairly  close  agreement  between  representation  of  diseases  and 
conditions  in  the  Company's  general  Nursing  Service  for  1915, 
and  in  the  emmierations  of  the  sickness  survey  of  July,  1916. 

Economic  Loss  From  Sickness  in  Boston. 

In  both  the  Rochester  and  North  Carolina  surveys  our 
findings  were  for  many  reasons  minimal.  Likewise,  the 
seasonal  conditions  in  Boston  during  July  were  so  favorable  as 
to  result  in  a  low  sickness  rate  in  this  investigation.  Compu- 
tations of  the  amounts  of  physical  disability  due  to  sickness 
and  accident  on  the  basis  of  our  findings  may  be  expected, 
therefore,  to  produce  conservative  figures.  The  estimated  male 
population  of  Boston,  15  years  and  over,  in  1916  is  272,219. 
On  the  basis  of  the  sickness  rate  determined  by  this  survey 
for  these  ages  (21.6  per  thousand)  we  may  conclude  that  there 
are  at  least  5,880  males  in  Boston  constantly  sick  and  disabled. 
At  300  working  days  per  year  per  individual,  there  is  a  loss  of 
1,764,000  working  days  or  6.5  working  days  per  individual. 
This  average  of  time  loss  for  sickness  and  accident  per  male 
in  the  general  community  may  be  compared  with  7.6  days  for 
the  vState  of  North  Carolina  and7.0days  for  the  city  of  Rochester. 
The  latest  available  figure  for  males  of  working  age  in  the  Local 
Sick  Benefit  Societies  of  Germany,  namely,  for  the  year  1913, 
shows  an  average  of  8.8  days  of  disability  for  work  per  year. 

In  like  manner,  the  286,081  females  of  working  age  may  be 
expected  to  give  a  total  of  6,237  persons  constantly  sick,  which 
at  300  working  days  per  year  per  individual,  gives  a  total  loss 
of  1,871,100  working  days,  or  an  average  of  6.5  days  per  indi- 
vidual per  year.  The  corresponding  figure  for  the  Rochester 
surv^ey  was  7.7  days;  for  North  Carolina  10.2  and  for  the  latest 
German  Sickness  Society  experience,  9.8  days. 

Conclusion. 
The  following  are  the  principal  findings  of  the  present  survey : 
1 .    Close  to  2%  of  the  population  of  Boston  was  found  to  be 
sick.    This  proportion  is  smaller  than  that  registered  in  pre- 
vious surveys. 

22 


2.  Slightly  more  than  90%  of  the  total  cases  of  sickness 
involved  disability  for  work. 

3.  The  principal  diseases  responsible  for  the  sickness  regis- 
tered were  rheumatism,  organic  diseases  of  the  heart,  tubercu- 
losis of  the  lungs,  diseases  of  the  kidneys  and  diseases  and 
conditions  of  the  puerperal  state. 

4.  The  proportion  of  cases  sick  less  than  one  month  up 
to  the  date  of  the  survey  was  only  26.3%  of  the  total.  This 
was  slightly  higher  than  the  finding  for  Rochester,  N.  Y.,  but 
considerably  lower  than  the  proportion  of  cases  sick  less  than 
one  month  in  North  Carolina.  The  relatively  small  number 
of  cases  of  the  acute  infectious  diseases  accounted  for  this 
condition. 

5.  Of  the  total  cases  72.9%  received  medical  attention ;  this 
is  a  higher  percentage  than  that  developed  in  either  of  the  preced- 
ing surveys.  This  finding  reflects  the  excellent  medical  facilities 
available  in  the  city  of*  Boston.  Hospitals  and  dispensaries 
provided  a  large  proportion  of  the  total  amount  of  medical  care. 

6.  The  economic  loss  resulting  from  sickness  in  Boston  is 
considerable,  involving  the  loss  of  earnings  for  about  seven  days 
per  person  per  year. 


23 


COLUMBIA   UNIVERSITY 

This   book  is  due  on  the  date  indicated  lielow.  or  at  the 
expiration  of  a  definite  period  after  the  date  of  borrowing, 
as  provided  by  the  rules  of  the  Library  or  by  special  ar- 
rangement with  the  Librarian  in  charge. 

DATE  BORROWED 

DATE   DUE 

DATE  BORROWED 

DATE  DUE 

|Ki«i96 

! 

A 

^^ 

^/?/7 

'%> 

V^ 

C28'636)MS0 

RA807.1/.38  '  ^^^ 

Frankel 
^    siotoiess  survey  of  Boston^llass. 


